Uncertainty, Action, and Medical Errors

doctorgaze
By Abdul El-Sayed

As a medical student, you’re taught that medicine is “more of an art than a science.” It’s an adage that’s usually invoked to explain why, sometimes, errors are made. Throughout my first several years of medical school, before I’d had any real experience working in the clinic, I always thought this to be a lame excuse for poor clinical practice.

Sure, the interpersonal aspects of medical care are certainly less scientific. Communicating effectively and comforting another person going through a terrible experience is more about empathy, compassion, and reassurance than it is about science. But science is what differentiates a doctor from anyone else in an ill person’s life. In the end, people trust doctors to understand, interpret, and apply medical science to provide them the best possible care.

So if science is medicine’s competitive advantage, why is medicine more an art than a science?

As a student in a dual MD and PhD training program, I left medical school after my first two years to pursue four years of scientific training as an epidemiologist before returning to begin my clinical rotations. Trading the ivory towers of Oxford and Columbia for the hospital wards of the Bronx was certainly a culture shock. While I had prepared for the changes in environment, workflow, and pace, there was one change for which I was wholly unprepared.

I had spent the last four years working with like-minded colleagues, thinking deeply about conceptual issues in epidemiology and public health. Questions about the meaning of inequality, how policy shapes social and behavioral decisions, and methodological approaches to answering difficult causal questions using imperfect data dominated my professional life. And like those of most scientists, many of the questions that I asked didn’t have solid answers — not yet, at least. But that was okay. Our problems weren’t time-delimited. We could wait until tomorrow.

But as a medical student, working alongside physicians to ask more minute, yet imminent questions about the pathophysiology underlying the symptoms with which my patients were presenting, no answer meant no way forward. And that was not okay — tomorrow might be too late. Trained as a scientist, I was uncomfortable with the uncertainty of our putative answers. They were they best we had, but they could easily be wrong.

This was the case for one patient, Mr. M. He had come in with meningitis, an infection of his brain’s protective covering requiring immediate treatment, lest it spread to the vital organ just beneath it. Because it was unclear what the infecting bug was, however, and finding out would take several days or more, we treated him with a cocktail of drugs to cover a broad range of potential microbes, including bacteria and fungi. Unfortunately, while it was impossible to know at the time, Mr. M had an allergy to the drug used to treat fungal infections.

Mr. M’s organs broke down, one by one. First came the skin rashes — painful eruptions across his back and torso. Next came the jaundice, a yellowing of his skin resulting from his failing liver. Eventually, his kidneys and heart began to crash. Mr. M would survive, but only after a long and painful month in the hospital.

Frustratingly, the whole ordeal could have been avoided — at least in theory. It turns out that Mr. M’s infection was not the result of a fungus, and the drug that caused his allergic reaction wasn’t even necessary to begin with.

But theory isn’t practice. Had the infection actually turned out to be fungal, it could have rapidly spread to the brain, causing serious long-term damage, or even death. With precious time wasting, we had to do the best we could with limited information — and that meant treating him for what was potentially a fungal infection, risking the potential side-effects of the treatment.

The source of my discomfort in this new-found setting was the lesson my medical professors, silver-haired veterans of the wards, had been trying to teach me all along: medicine is not a science because the level of certainty needed to act is not nearly as high. In science, it’s okay not to have a clear answer right now, or even tomorrow. In fact, science keeps going because there is no clear answer. In medicine, however, even if doctors aren’t confident, there must always be a working answer. Risk is an obligate part of the enterprise.

And with risk comes errors. Even in the best of circumstances, doctors often have to be comfortable with the fact that the working answer may not be the correct answer, yet they must act on it as if it were. And because, in some cases, the working answer is incorrect, errors are made: diagnoses are wrong, inappropriate treatments are given, and people are hurt.

The art of medicine — what I’m learning now — is in practicing how to minimize those errors and respond when they occur.

Edited by Karestan Koenen.

Article originally posted on the2x2project.org, an online publication sponsored by the Department of Epidemiology at Columbia University. 2×2 aims to inform the health conversation through timely and effective communication of emerging public health science.

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